| NPI | 1770110520 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 2417199-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2020-03-23 |
| Last Update Date | 2023-09-21 |